Basic Information
| Provider Information | |||||||||
| NPI: | 1255494092 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEDINA | ||||||||
| FirstName: | TYRONE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 8TH ST N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392615511 | ||||||||
| FaxNumber: | 2396493301 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 8TH ST N | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341025519 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392615511 | ||||||||
| FaxNumber: | 2396493301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2006 | ||||||||
| LastUpdateDate: | 11/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME59671 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | ME0059671 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00107425 | 01 | FL | RRMC | OTHER | 12203 | 01 | FL | BCBS | OTHER | 371615500 | 05 | FL | MEDICAID |